‘Okay, I get that alternating unilateral head pain is a musculoskeletal event’, affirms Watson’s colleague, ‘but I was discussing this with a psychologist colleague of mine who pointed to numerous studies highlighting the increased prevalence of depression and anxiety in those with migraine, perhaps implying a causal role’.
Does Migraine Result from Depression, or Is Depression the Result of Migraine?
‘Yes, many patients are told that depression and or anxiety are causing their migraine’, replies Watson. ‘This is not surprising, given that most with migraine have long histories spanning decades. I would be depressed, too, if I have had constant headache for ten years, or two to three migraine episodes a week, or being bedridden for 25% of my life.’
‘Well… Yes, I guess I would be too,’ acknowledges Watson’s colleague.
Watson continues, “However, debate continues as to whether psychological distress precedes and causes chronic pain or, conversely, psychological distress is a consequence of chronic pain.”
The Prejudice of the Biopsychosocial Model
“It is recognised that personal psychological variables are not risk factors for chronicity,” explains Watson. “The biopsychosocial model invites medical denial – it is easy and convenient to assume that chronic pain is entirely biopsychosocial with no biomedical basis. The biopsychosocial concept is prejudicial to chronic headache patients if the pain is attributed, without valid evidence, to biopsychosocial factors, and the cause of pain is ignored or pursued unconvincingly”.
“Furthermore”, continues Watson, “this is compounded in situations where progress has been disappointing (particularly if the treatment history involves multiple practitioners), for it is even more attractive and convenient to focus on the biopsychosocial factors, but this is neither reliable nor valid. There are no objective diagnostic criteria. A ‘psychological’ diagnosis, to the exclusion of a biomedical one, is no more than an opinion.”
The Perils of Pointing the Finger
Watson’s vexation continues, “It is prudent, in the event of unsuccessful outcomes, to remember the sagacious saying, ‘when you point one finger, three fingers are pointing back at you’; blaming psychological factors, when the evidence suggests that psychological factors are not instrumental in the outcomes of chronic headache patients, is pernicious. Perhaps it says more about the shortcomings of the treating practitioner.”
The Psychology of Central Sensitisation
Watson’s colleague is surprised by the intensity of Watson’s frustration and attempts to digress, ‘Yes, I know that research demonstrates that psychological factors are not the main factors responsible for Central Sensitisation (CS) appears not to be affected, at least significantly, by psychological factors, and as we have discussed sensitisation of the Trigemino Cervical Complex is the underlying disorder in Migraine, indeed Primary Headache and chronicity in headache generally.’
The Vanishing Act!
“So, why is there ongoing debate as to whether psychological distress precedes and causes migraine or, conversely, whether psychological distress is a consequence of migrainous symptoms?” queries Watson. “The literature (and clinical experience) suggests that it is not in the patient’s best interests to focus on biopsychosocial factors in chronic headache; changing patients’ pain by identifying and successful intervention of relevant biomedical sources (CS) is the most powerful instrument in successful outcomes.”
“Okay, I get it.” Watson’s colleague concedes, “If the evidence suggests that psychological factors are not instrumental in the outcomes of chronic headache patients, and whilst psychological, behavioural, and lifestyle factors may influence a physical disorder in chronic headache patients at various times, identifying and managing relevant biomedical conditions should be, and is the focus, thus ensuring the provision of a committed service.”
“Yes, precisely my point,” exclaims Watson.
